TEMPORARY WATER AND WASTEWATER CERTIFICATION APPLICATION

Department of Environmental Quality
NOTICE
NEW PROCEDURES FOR OBTAINING
AGENCY ISSUED LICENSES/CERTIFICATIONS
Effective November 1, 2007
In order to comply with Oklahoma’s new immigration law, 56 Okla. Stat. § 71, the Oklahoma Department of Environmental Quality has established the following new procedures for an individual to obtain an agency-issued license/certification.
A. In order to obtain a license/certification or to renew an existing license/certification, the documentation requested in Sections C and E, including a signed Affidavit Regarding Citizenship, is required. In the absence of the required documentation, citizenship and immigration status cannot be determined and applicants may not be eligible for the license/certification for which they are applying.
B. The Department of Environmental Quality will have available notary public services for the Affidavit Regarding Citizenship at no cost to the applicant at the main office located at 707 N. Robinson, Oklahoma City, Oklahoma 73101 during regular business hours (8:00 a.m. – 4:30 p.m. Monday through Friday, except holidays).
C. The following documents must be provided to the agency with the relevant license/certification application in order to establish eligibility:
ALL U.S. CITIZENS
1. A signed and notarized Affidavit Regarding Citizenship (see attached affidavit)
ALL NON-U.S. CITIZENS:
If you are not a U.S. Citizen, but are a qualified alien under the federal Immigration and Nationality Act and are lawfully present in the U.S. to work, please provide one of the documents listed in Section E, along with the Affidavit Regarding Citizenship.
D. The Oklahoma Department of Environmental Quality participates in the Systematic Alien Verification for Entitlements (SAVE) Program, which is an intergovernmental information-sharing initiative designed to aid in determining a non-citizen applicant’s immigration status (lawful presence), and thereby ensuring only eligible non-citizens receive government benefits, such as licenses/certifications.
E. The Oklahoma Department of Environmental Quality will only issue licenses/certifications to Qualified Aliens (non-U.S. citizens) who present valid documentary evidence of one (1) of the following:
 Unexpired foreign passport, with I-551 stamp, or attached Form I-94 indicating unexpired employment authorization;
 Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151, or I-551);
 Unexpired Temporary Resident Card (Form I-688); Unexpired Employment Authorization Card (Form I-688A)
 Unexpired Reentry Permit (Form I-327);
 Unexpired Refugee Travel Document (Form I-571);
 Unexpired Employment Authorization Document issued by Department of Homeland Security (“DHS”) containing a photograph (Form I-688B);
 Valid unexpired immigrant or non-immigrant visa status for admission into the United States;
 Pending or approved application for asylum in the United States;
 Pending or approved application for temporary protected status in the United States;
 Approved deferred action status (Aliens whose deportation is being withheld under (1) § 243(h) of the Immigration and Nationality Act (“INA”) as in effect prior to April 1, 1997 or (2) § 241(b)(3) of the INA;
 Pending application for adjustment of status to legal permanent resident or conditional resident status. (Aliens granted conditional entry under § 2039 (a)(7) of the INA before April 1, 1980). (Upon approval, the applicant may be issued a temporary license/certification for the period of time of the authorized stay in the U.S., or if there is no definite end to the period of authorized stay, then for period of one (1) year);
 Cuban and Haitian Entrants, as defined in § 501(e) of the Refugee Education Assistance Act of 1980;
 Aliens granted parole for at least one year under § 212(d)(5) of the INA;
 Battered aliens, who meet the conditions set forth in § 431(c) of Personal Responsibility and Work Opportunity Reconciliation Act (“PRWORA”) as added by § 501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208 (IIRIRA), and amended by § 5571 of the Balanced Budget Act of 1997, P.L. 105-33 (BBA), and § 1508 of the Violence against Women Act of 2000, P.L. 106-386. Section 431(c) of PRWORA, as amended, is codified at 8 U.S.C. 1641(c);
 Victims of a severe form of trafficking, in accordance with § 107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.
F. Complying with the above requirements does not guarantee issuance of a license/certification. Applicants must still satisfy all other required qualifications of the respective licenses/certifications for which they are applying.
G. RENEWALS:
Effective November 1, 2007, all applicants will be required to present the documentation listed in Sections C and E to establish eligibility. All licenses/certifications may be renewed upon expiration by, in addition to satisfying any other preconditions required by the particular license/certification, mailing a renewal application and any applicable renewal fee. For renewal applicants that have already demonstrated citizenship by satisfying the requirements set forth in Section C above in his/her original application or a prior renewal application, the applicant shall not be required to resubmit such documentation. For renewal applicants that identify themselves as a “qualified alien lawfully present” in the Affidavit Regarding Citizenship, the documents listed in Section E must be resubmitted to the Oklahoma Department of Environmental Quality with the renewal application in order to demonstrate that the applicant’s lawful status has not changed. Department of Environmental Quality
AFFIDAVIT REGARDING CITIZENSHIP
I, ________________________________________ (Print name) swear under a penalty of perjury, that I am
(Check one) __________ a United States citizen; or
__________ a qualified alien lawfully present in the United States, and I authorize the United States Department of Homeland Security to release my citizenship and immigration Oklahoma Department of Environmental Quality in order to be eligible to receive the benefit/license/certification for which I am applying*
___________________________________
Signature License/certification Applicant
* Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in this affidavit shall be subject to criminal penalties applicable in the State of Oklahoma for fraudulently obtaining a public assistance program benefit (a license/certification). If the affidavit constitutes a false claim of U.S. citizenship under 18 U.S.C. Section 911, a complaint will be filed by the Oklahoma Department of Environmental Quality with the United States Attorney for the applicable district based upon the venue in which the affidavit was executed.
ACKNOWLEDGEMENT
State of __________________________ )
) ss:
County of ________________________ )
Subscribed and sworn to before me this __________ day of __________, 20____.
___________________________
Notary Public
My Commission expires:_______________________TEMPORARY WATER AND WASTEWATER CERTIFICATION APPLICATION
WATER LICENSE #___________________ DEQ OFFICE USE ONLY
Project ID 292010911
WASTEWATER LICENSE #______________ DATE LICENSE MAILED___________________
PLEASE RETURN APPLICATION TO: Department of Environmental Quality
Financial & Human Resources
PO Box 2036
Oklahoma City, OK 73101-2036
Incomplete or incorrect applications may be returned.
Name-Last:_________________________First:___________________MI:_______
Address___________________________City_________________State______Zip_____________
Social Security #*______________ Birthdate ________________Home Phone_________________
Job Title__________________________Type of Work Performed___________________________
Do you supervise other operators or helpers? ________
Employer_________________________Address_____________________City________________
State________Zip_____________Office Phone_________________________
Employer’s Water Facility ID#__________________Employer’s Wastewater Facility ID#_______________
If you have held a temporary Oklahoma water and/or wastewater license within the last five years, you are not eligible to apply at this time. Temporary license fees are $62.00 each and must be mailed with your application.
Payment form is located at the bottom of the second page.
Please indicate below which you are applying for:
100841 100131
Temporary Water Works Temporary Wastewater Works
The following information is for the name of the permanently certified operator who will supervise your work as a water and/or wastewater works operator during the period in which you are not permanently certified.
Name_________________________________ Address___________________________________
City_____________________State_________Zip__________________
Water License #_________________________ Wastewater License #_____________________
I Certify that I have agreed to train, advise or supervise this applicant’s work as a water and/or wastewater
operator and will notify the Department of Environmental Quality if my services are terminated prior to the applicant receiving permanent operator status.
Supervisor’s Signature_________________________________ Date Signed_______________________
Rev 05/2011
*Pursuant to OAC 710:95-9-3(a), DEQ must provide to the Oklahoma Tax Commission (“OTC”) a list of all its licensees along with their social security numbers and other identifying information that may be required by OTC. Education: Highest grade or degree completed____________________________________________
Experience: List your experience in water and/or wastewater systems operations or maintenance:
Describe your duties in detail:____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Statement of Understanding: I hereby certify under penalty of law that this application contains no willful or negligent misrepresentation or falsification and that all information is true, accurate and complete. I understand that any misrepresentation or falsification may result in rejection of my application for temporary certification. I further understand that if issued a temporary operator certificate, it is not renewable and a new temporary certificate cannot be obtained for at least five (5) years. Therefore, if I am to continue working as a water or wastewater works operator I must qualify for and pass the proper written examination for permanent certification before expiration of my temporary certificate (s). I further understand that this application must be signed by a permanently certified operator who will be giving general supervision of my work as a water and/or wastewater operator. I agree to notify you if his services are terminated before I can obtain the proper permanent certification.
Signature of Applicant__________________________________________
Date Employment Began_______________________________(License will expire 1 year from this date)
Rev 05/2011
PLEASE CHOOSE FORM OF PAYMENT
APPLICATION CANNOT BE PROCESSED WITHOUT PAYMENT.
CHECK ENCLOSED
MADE PAYABLE TO DEQ
CHECK #
MONEY ORDER ENCLOSED
MADE PAYABLE TO DEQ
MONEY ORDER #
PURCHASE ORDER
PURCHASE ORDER #
CREDIT CARD: MUST BE VISA OR MASTERCARD
SIGNATURE:
EXPIRATION DATE:
CREDIT CARD #:

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Department of Environmental Quality
NOTICE
NEW PROCEDURES FOR OBTAINING
AGENCY ISSUED LICENSES/CERTIFICATIONS
Effective November 1, 2007
In order to comply with Oklahoma’s new immigration law, 56 Okla. Stat. § 71, the Oklahoma Department of Environmental Quality has established the following new procedures for an individual to obtain an agency-issued license/certification.
A. In order to obtain a license/certification or to renew an existing license/certification, the documentation requested in Sections C and E, including a signed Affidavit Regarding Citizenship, is required. In the absence of the required documentation, citizenship and immigration status cannot be determined and applicants may not be eligible for the license/certification for which they are applying.
B. The Department of Environmental Quality will have available notary public services for the Affidavit Regarding Citizenship at no cost to the applicant at the main office located at 707 N. Robinson, Oklahoma City, Oklahoma 73101 during regular business hours (8:00 a.m. – 4:30 p.m. Monday through Friday, except holidays).
C. The following documents must be provided to the agency with the relevant license/certification application in order to establish eligibility:
ALL U.S. CITIZENS
1. A signed and notarized Affidavit Regarding Citizenship (see attached affidavit)
ALL NON-U.S. CITIZENS:
If you are not a U.S. Citizen, but are a qualified alien under the federal Immigration and Nationality Act and are lawfully present in the U.S. to work, please provide one of the documents listed in Section E, along with the Affidavit Regarding Citizenship.
D. The Oklahoma Department of Environmental Quality participates in the Systematic Alien Verification for Entitlements (SAVE) Program, which is an intergovernmental information-sharing initiative designed to aid in determining a non-citizen applicant’s immigration status (lawful presence), and thereby ensuring only eligible non-citizens receive government benefits, such as licenses/certifications.
E. The Oklahoma Department of Environmental Quality will only issue licenses/certifications to Qualified Aliens (non-U.S. citizens) who present valid documentary evidence of one (1) of the following:
 Unexpired foreign passport, with I-551 stamp, or attached Form I-94 indicating unexpired employment authorization;
 Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151, or I-551);
 Unexpired Temporary Resident Card (Form I-688); Unexpired Employment Authorization Card (Form I-688A)
 Unexpired Reentry Permit (Form I-327);
 Unexpired Refugee Travel Document (Form I-571);
 Unexpired Employment Authorization Document issued by Department of Homeland Security (“DHS”) containing a photograph (Form I-688B);
 Valid unexpired immigrant or non-immigrant visa status for admission into the United States;
 Pending or approved application for asylum in the United States;
 Pending or approved application for temporary protected status in the United States;
 Approved deferred action status (Aliens whose deportation is being withheld under (1) § 243(h) of the Immigration and Nationality Act (“INA”) as in effect prior to April 1, 1997 or (2) § 241(b)(3) of the INA;
 Pending application for adjustment of status to legal permanent resident or conditional resident status. (Aliens granted conditional entry under § 2039 (a)(7) of the INA before April 1, 1980). (Upon approval, the applicant may be issued a temporary license/certification for the period of time of the authorized stay in the U.S., or if there is no definite end to the period of authorized stay, then for period of one (1) year);
 Cuban and Haitian Entrants, as defined in § 501(e) of the Refugee Education Assistance Act of 1980;
 Aliens granted parole for at least one year under § 212(d)(5) of the INA;
 Battered aliens, who meet the conditions set forth in § 431(c) of Personal Responsibility and Work Opportunity Reconciliation Act (“PRWORA”) as added by § 501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208 (IIRIRA), and amended by § 5571 of the Balanced Budget Act of 1997, P.L. 105-33 (BBA), and § 1508 of the Violence against Women Act of 2000, P.L. 106-386. Section 431(c) of PRWORA, as amended, is codified at 8 U.S.C. 1641(c);
 Victims of a severe form of trafficking, in accordance with § 107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.
F. Complying with the above requirements does not guarantee issuance of a license/certification. Applicants must still satisfy all other required qualifications of the respective licenses/certifications for which they are applying.
G. RENEWALS:
Effective November 1, 2007, all applicants will be required to present the documentation listed in Sections C and E to establish eligibility. All licenses/certifications may be renewed upon expiration by, in addition to satisfying any other preconditions required by the particular license/certification, mailing a renewal application and any applicable renewal fee. For renewal applicants that have already demonstrated citizenship by satisfying the requirements set forth in Section C above in his/her original application or a prior renewal application, the applicant shall not be required to resubmit such documentation. For renewal applicants that identify themselves as a “qualified alien lawfully present” in the Affidavit Regarding Citizenship, the documents listed in Section E must be resubmitted to the Oklahoma Department of Environmental Quality with the renewal application in order to demonstrate that the applicant’s lawful status has not changed. Department of Environmental Quality
AFFIDAVIT REGARDING CITIZENSHIP
I, ________________________________________ (Print name) swear under a penalty of perjury, that I am
(Check one) __________ a United States citizen; or
__________ a qualified alien lawfully present in the United States, and I authorize the United States Department of Homeland Security to release my citizenship and immigration Oklahoma Department of Environmental Quality in order to be eligible to receive the benefit/license/certification for which I am applying*
___________________________________
Signature License/certification Applicant
* Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in this affidavit shall be subject to criminal penalties applicable in the State of Oklahoma for fraudulently obtaining a public assistance program benefit (a license/certification). If the affidavit constitutes a false claim of U.S. citizenship under 18 U.S.C. Section 911, a complaint will be filed by the Oklahoma Department of Environmental Quality with the United States Attorney for the applicable district based upon the venue in which the affidavit was executed.
ACKNOWLEDGEMENT
State of __________________________ )
) ss:
County of ________________________ )
Subscribed and sworn to before me this __________ day of __________, 20____.
___________________________
Notary Public
My Commission expires:_______________________TEMPORARY WATER AND WASTEWATER CERTIFICATION APPLICATION
WATER LICENSE #___________________ DEQ OFFICE USE ONLY
Project ID 292010911
WASTEWATER LICENSE #______________ DATE LICENSE MAILED___________________
PLEASE RETURN APPLICATION TO: Department of Environmental Quality
Financial & Human Resources
PO Box 2036
Oklahoma City, OK 73101-2036
Incomplete or incorrect applications may be returned.
Name-Last:_________________________First:___________________MI:_______
Address___________________________City_________________State______Zip_____________
Social Security #*______________ Birthdate ________________Home Phone_________________
Job Title__________________________Type of Work Performed___________________________
Do you supervise other operators or helpers? ________
Employer_________________________Address_____________________City________________
State________Zip_____________Office Phone_________________________
Employer’s Water Facility ID#__________________Employer’s Wastewater Facility ID#_______________
If you have held a temporary Oklahoma water and/or wastewater license within the last five years, you are not eligible to apply at this time. Temporary license fees are $62.00 each and must be mailed with your application.
Payment form is located at the bottom of the second page.
Please indicate below which you are applying for:
100841 100131
Temporary Water Works Temporary Wastewater Works
The following information is for the name of the permanently certified operator who will supervise your work as a water and/or wastewater works operator during the period in which you are not permanently certified.
Name_________________________________ Address___________________________________
City_____________________State_________Zip__________________
Water License #_________________________ Wastewater License #_____________________
I Certify that I have agreed to train, advise or supervise this applicant’s work as a water and/or wastewater
operator and will notify the Department of Environmental Quality if my services are terminated prior to the applicant receiving permanent operator status.
Supervisor’s Signature_________________________________ Date Signed_______________________
Rev 05/2011
*Pursuant to OAC 710:95-9-3(a), DEQ must provide to the Oklahoma Tax Commission (“OTC”) a list of all its licensees along with their social security numbers and other identifying information that may be required by OTC. Education: Highest grade or degree completed____________________________________________
Experience: List your experience in water and/or wastewater systems operations or maintenance:
Describe your duties in detail:____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Statement of Understanding: I hereby certify under penalty of law that this application contains no willful or negligent misrepresentation or falsification and that all information is true, accurate and complete. I understand that any misrepresentation or falsification may result in rejection of my application for temporary certification. I further understand that if issued a temporary operator certificate, it is not renewable and a new temporary certificate cannot be obtained for at least five (5) years. Therefore, if I am to continue working as a water or wastewater works operator I must qualify for and pass the proper written examination for permanent certification before expiration of my temporary certificate (s). I further understand that this application must be signed by a permanently certified operator who will be giving general supervision of my work as a water and/or wastewater operator. I agree to notify you if his services are terminated before I can obtain the proper permanent certification.
Signature of Applicant__________________________________________
Date Employment Began_______________________________(License will expire 1 year from this date)
Rev 05/2011
PLEASE CHOOSE FORM OF PAYMENT
APPLICATION CANNOT BE PROCESSED WITHOUT PAYMENT.
CHECK ENCLOSED
MADE PAYABLE TO DEQ
CHECK #
MONEY ORDER ENCLOSED
MADE PAYABLE TO DEQ
MONEY ORDER #
PURCHASE ORDER
PURCHASE ORDER #
CREDIT CARD: MUST BE VISA OR MASTERCARD
SIGNATURE:
EXPIRATION DATE:
CREDIT CARD #: